Medical Director (Utilization Management)

Title: Medical Director (Utilization Management)
Location: Remote - candidates must be comfortable working PST hours
Start Date: Monday, November 10, 2025
Position Type: Contract

Assignment Details

The Medical Director (Utilization Management) plays a key leadership role in ensuring the clinical integrity of the utilization management (UM) function, with a particular focus on inpatient and post-acute care reviews. Reporting to the Chief Medical Officer, this physician leader will ensure care determinations are clinically appropriate, compliant with CMS regulations, and aligned with evidence-based guidelines.

Key Responsibilities

• Conduct timely utilization review and medical necessity determinations for inpatient admissions, continued stays, and post-acute care services (SNF, IRF, LTACH, home health) for Medicare Advantage members.
• Apply MCG and InterQual guidelines as well as CMS criteria to assess the appropriateness of acute care services.
• Serve as the physician reviewer for complex or escalated UM cases requiring clinical judgment.
• Collaborate with utilization and care management teams to ensure consistent, cost-effective, and patient-centered care decisions.
• Participate in peer-to-peer discussions with attending physicians to clarify documentation and support proper levels of care.
• Identify utilization trends and assist in developing interventions to reduce unnecessary admissions or extended stays.
• Contribute to the development and implementation of medical policy and UM protocols.
• Support CMS regulatory compliance, audit preparedness, and delegated oversight activities.
• Participate in UM committee meetings and represent the organization in provider or stakeholder engagements.
• Ensure all documentation meets NCQA, CMS, and internal standards.

Qualifications

Required:

• Licensed M.D. or D.O., in good standing in the state of residence.
• Minimum 5 years of clinical experience, including 3 years in a utilization management or medical leadership role within a managed care or health plan setting.
• Strong knowledge of Medicare Advantage regulations and CMS coverage criteria.
• Experience with MCG and InterQual guidelines.
• Excellent communication, analytical, and negotiation skills.
• Proficiency with MS Office and medical management systems.
• Ability to maintain strict confidentiality and adhere to HIPAA and organizational standards.

Preferred:

• MPH, MBA, or MHA.
• Certification by the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP).

You’ll Excel In This Role If You Have:

• Deep knowledge of MCG criteria and evidence-based utilization management.
• Experience leveraging data to design population health and clinical improvement programs.
• Strong interpersonal skills with the ability to engage effectively across matrixed teams.
• Proven ability to drive collaboration, mentor clinical staff, and ensure compliance with state and federal documentation standards.
• Exceptional attention to detail and the ability to make sound, timely medical decisions.